Despite the advances made in technologies such as medical imaging to assist the physician in early stage diagnosis and treatment of patients with possible atypical tissue such as cancer, it is still often necessary to sample difficult-to-reach organ or tissue lesions by biopsy to confirm the presence or absence of abnormalities or disease.
A disease for which biopsy is a critical tool is breast cancer. This affliction is responsible for 18% of all cancer deaths in women and is the leading cause of death among women aged 40 to 55. As with many diseases and other types of cancer, early detection and diagnosis of breast cancer is critical in providing the best chance of survival.
In the majority of cases, detection of the disease is first made when a patient discovers a palpable mass through self-examination and consults her physician. For breast lesions that are more difficult or impossible to detect through palpation, diagnostic techniques such as x-ray mammography and, more recently, digital mammography, and scintamammography are invaluable. Other techniques such as ultrasound, magnetic resonance, the Dilon gamma camera, position emission tomography, MIBI, computed topography, fluoroscopy, thermography, transillumination and diaphanography can also be used to help determine the presence and nature of suspect tissue.
Of these technologies, the primary clinical diagnostic tool for the detection of breast cancer is x-ray mammography. Over 15 million mammograms are performed each year in the United States alone. Mammography uses x-rays to image breast tissue, identifying areas of high density as possible lesions.
Unfortunately, the limitations of technologies such as mammography in accurately detecting precancerous or cancerous lesions in the breast are significant. Among these limitations is the fact that only one out of every five lesions discovered through x-ray mammography proves to be cancerous. Roughly 25% of women have dense breast tissue, which is notoriously difficult to inspect via mammography. Also, mammography is generally less effective for women under 40 years of age. For younger women, therefore, self-examination for palpable lesions or ultrasound examination is important. However, neither of these techniques is able to detect microcalcifications, important possible precursors to cancer.
As long as there is a degree of uncertainty associated with these various diagnostic techniques, biopsies must be performed to sample the suspicious tissue to determine its exact nature and pathology.
In the detection and treatment of breast cancer, there are two general classes of biopsy: the minimally invasive percutaneous fine or core needle biopsy and the more invasive surgical or "open" biopsy.
Open biopsies, both incisional and excisional, are advisable when suspicious lumps should be removed in their entirety or when core needle biopsies don't give complete information about the nature of the lesion.
One this type of open biopsy is the wire localization biopsy. Such a procedure includes the following steps: first, a radiologist inserts a wire into the breast under x-ray guidance to mark the location of the suspect tissue. The tissue is then removed by a surgeon for examination by a pathologist. Although large tissue samples are removed by this technique, the risk of permanent disfigurement, the attendant morbidity and mortality risks associated with surgery, and long hospital recovery times are but three of the many disadvantages associated with open surgical biopsies.
Of the less invasive class of percutaneous biopsies, the least invasive is known as a fine needle biopsy. For palpable lumps, a physician inserts a needle and syringe directly into the lump to obtain a cell sample which is then examined by a cytologist. For non-palpable lesions identified by x-ray mammography or other diagnostic tool, fine needle biopsies are often performed under stereotactic or ultrasonic guidance. Here, multiple mammograms are taken of the breast and the images are analyzed by a computer to determine the location of the suspect lesion in three dimensions. The physician then penetrates the breast with a needle, targeting the suspect region and removing a small number of cells. There are two significant drawbacks to fine needle biopsy techniques: first, several specimens must be taken to ensure the lesion is well-sampled. Secondly, the limited size of the specimens obtained under fine needle biopsy dictate that a skilled cytologist be involved to analyze the suspect cells out of context of the surrounding healthy tissue.
A second type of percutaneous needle biopsy used to obtain a larger specimen is known as a core biopsy. With this procedure, a larger needle is inserted into the breast via an incision in the skin under stereotactic or ultrasonic guidance. A spring-loaded device is then fired into the breast to obtain a single core sample of tissue, preferably through the center of the lesion. The larger specimen size (up to 20 mm in diameter) obtained by this technique can be more accurately read by a pathologist, who can analyze the suspect cells in the context of the surrounding tissue. Examples of such devices are described in U.S. Pat. No. Re. 34,056 and U.S. Pat. Nos. 4,944,308 and 4,953,558, the entirety of which are hereby incorporated by reference.
Traditionally, as with fine needle biopsies, core biopsies require multiple core samples, typically four to twenty, to ensure an accurately representative sample of the suspect region is profiled. This means that as many as twenty separate needle insertions must be made into the breast through the skin.
More recently developed needle biopsy technologies are directed to solving this problem by allowing multiple samples to be obtained through a single incision, such as that described in U.S. Pat. Nos. 5,709,697 and 5,782,775, the entirety of which are hereby incorporated by reference. One such technology, described in U.S. Pat. Nos. 5,526,822, 5,769,086, and 5,775,333, the entirety of which are hereby incorporated by reference, utilizes a trocar-tipped probe which is positioned in the breast under stereotactic or ultrasonic guidance to align the suspect lesion with an aperture that extends along a specified length of the probe. The tissue is then aspirated into the aperture where a rotating cutter in the probe is advanced distally to cut and capture tissue specimen into the probe lumen. The cutter is then withdrawn, transporting the specimen to a tissue collection chamber. Next, the probe, which is still in the breast, is radially rotated in position through a desired angle to align the aperture with another target tissue area. The steps of rotation, cutting, and collection, which can be automated and assisted by vacuum, are repeated until the desired number of samples is obtained.
Although this type of device requires only a small, single incision to obtain a number of core samples, each sample is still limited in size, requiring excision of multiple specimens for accurate pathologic diagnosis. As with other percutaneous excisional devices in which multiple specimens must be obtained, it is often difficult to reconstruct the spatial location and orientation of the suspect tissue as it resided in the breast prior to excision, resulting in a concomitantly difficult pathological analysis.
Another type of percutaneous excisional breast biopsy device designed to first separate healthy tissue from suspect tissue prior to obtaining a single suspect tissue sample is generally described in U.S. Pat. Nos. 5,111,828, 5,197,484, and 5,353,804, the entirety of which are hereby incorporated by reference. This device, however, requires the use of a relatively large diameter cannula to obtain an adequate specimen size.
What is needed is a small-diameter percutaneous excisional biopsy device that allows a physician to obtain, in a minimally invasive manner, a relatively large tissue specimen through a small incision. Further, what is needed is a device that can obtain a specimen large enough for a complete, accurate and satisfactory pathologic determination, obviating the need for obtaining multiple core specimens and reconstructing them ex vivo.